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abc
373
Fig. 35.6 (a) Pseudoaneurysm (blue arrow) at the level of origin of the
right supercial femoral artery and arteriovenous stula (orange arrow),
with lling of the common femoral vein at the same level. (b) Covered
Endovascular Repair
The appropriate endovascular intervention strategy is determined by the donor artery and the size of the pseudoaneurysm neck, which may be divided into two basic categories:
direct pseudoaneurysm embolization and donor artery stent
implantation.
Stent-Graft Placement
For stent-graft placement, a new vascular puncture site is
required, either on the ipsilateral limb with a direction toward
the pseudoaneurysm or from the contralateral groin with a
“cross-over” (across the aortic bifurcation) access, in the case
of the femoral artery (Fig.35.6). Placement of a stent- graft is
preferred in larger-diameter arteries since smaller arteries have
a greater thrombosis risk but are not completely ineligible for
the procedure. Cross-over approaches need a more rigid delivery system with the use of a long sheath because considerable
elongation and tortuosity of the iliac trunks are suspected to
have higher misplacement probability and procedure failure
rate. The normal range of motion of the hip joint may fracture
or occlude covered stents, making them unsuitable for joint
placement. At a mean follow-up of 301 days, Thalhammer
etal. reported stent occlusions in 17% of patients, aside from
the fact that all pseudoaneurysms were fully and permanently
excluded [40]. The high expense of stent-graft placement for
common usage in a potentially big patient population and the
prohibition of future catheterization of the stented artery are
two additional important limitations.
stent placed across the pseudoaneurysm and AVF. (c) Normal patency
of the femoral arteries following stent placement with no demonstration
of the pseudoaneurysm and no arteriovenous stula detected
ble, such as those that are near the inguinal ligament or the
femoral bifurcation, may be treated with an endovascular
catheter-directed insertion of coils into the sac itself [41].
When a pseudoaneurysm develops in an irreplaceable donor
artery, the donor artery must be protected from circulation to
avoid distal blood ow obstruction. If the pseudoaneurysm
cannot be superselectively catheterized for further embolization, embolization of the afferent artery is used only if it can
be spared functionally. Embolization must be performed
both proximally and distally in order to avoid backow into
the pseudoaneurysms, from collateral branches.
Nondetachable and detachable coils are the two primary
types of coils. Nondetachable coils take their form immediately after being released from the catheter, without the possibility of withdrawal. These coils are found in an extensive
variety of sizes, materials, and shapes formed. For a more
precise coil embolization, detachable coils can be used that
are connected to a pusher guidewire to readapt the coil placement, if necessary, before nal release. Some of these
patients might have pathological blood coagulation that
might result to incomplete thrombosis of the pseudoaneurysm, so the use of additional embolic agents, like thrombin
or histoacryl glue, can be used. Pseudoaneurysms may also
be treated by uncovered stent placement across their neck,
followed by coil embolization with the use of a catheter
directed through the mesh in the pseudoaneurysm. This technique prevents migration of coils in the healthy vessel,
although the main disadvantage is that lifelong use of antiplatelet medication is required.
Coil Embolization
Pseudoaneurysms that cannot be treated percutaneously or
where the implantation of an endovascular stent is not feasi-
Thrombin Injection
Endovascular thrombin injection can be used in pseudoaneurysms that are inconveniently located for percutaneous
374
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O. Moschovaki-Zeiger et al.
embolization. This procedure entails selective catheterization of the pseudoaneurysmal neck with an appropriate endovascular catheter and the injection of thrombin directly into
the false aneurysm lumen.
Surgical Repair
Iatrogenic and non-iatrogenic pseudoaneurysms that cannot
be treated by percutaneous procedures are candidates for surgical repair. Since less invasive ways of treating pseudoaneurysms have been developed, the use of surgery to repair them
has become less common. The fact that these innovative
methods may be done under local anesthesia is a great advantage for patients with comorbidities that are at great risk of
needing general anesthesia. In addition, the length of hospital stay is longer that 3days on average [42]. Surgical repair
for pseudoaneurysms is preserved for a limited number of
cases in which it is necessary [43, 44]:
Rapid growth of the pseudoaneurysm
Infected/mycotic pseudoaneurysm
Distal limb ischemia, overlying skin ischemia, and neuropa-
thy (adjacent nerve compression) caused by local pres-
sure of the pseudoaneurysm or the hematoma
Unsuccessful percutaneous intervention
Vascular anastomotic disruption
Due to local scarring, after surgical repair, subsequent
groin access may be difcult in future interventions [42]. In
addition, it extends the hospital stay and raises the overall
healthcare expenses. False aneurysms that have become
infected necessitate immediate surgical intervention, as they
may rupture or cause septic emboli in the systemic circulation. These pseudoaneurysms must be treated surgically, as
the use of materials like coils or thrombin is contraindicated
due to them becoming contaminated and worsening the clinical condition of the patient [3].
Case Presentation
Continued from page 371
Ultrasound-guided local anesthesia was performed on
the left groin, and arterial access was obtained with
ultrasound- guided retrograde puncture of the left common
femoral artery, followed by insertion of a 6-French sheath
toward the external iliac artery. The right common iliac and
external iliac arteries were catheterized using the “crossover” technique with a Simmons-1 guiding catheter and a
0.035 Glidewire (Fig.35.7a). Angiography from the level
of the common femoral artery veried the origin of the
pseudoaneurysm from the right deep femoral artery.
Selective catheterization of the deep femoral artery was
performed, which was followed by superselective catheterization of the feeding branch, with the use of a 2.7 Fr
microcatheter (ASAHI; Japan) (Fig.35.7b, c). Embolization
was performed with the use of ve 4 mm micro-nester
pushable coils (Fig.35.8a, b). Control angiography depicted
a remaining lling of the pseudoaneurysm from another
feeding branch originating from the deep femoral artery, so
superselective catheterization and further embolization followed with the use of Glue- Lipiodol mixture, with a dilution of 1:1 (Fig.35.8c). Finally, control angiography from
the proximal deep femoral artery did not depict the pseudoaneurysm or areas of extravasation (Fig.35.8d).
Following removal of the catheters and the sheath, hemostasis of the left common femoral artery was obtained with
the use of a StarClose closure device.
The patient exited the angio-suite with physiological vital
signs and was discharged 2days later. At 1-month follow-up the
hematoma had completely resolved, and there was no visible
pseudoaneurysm according to ultrasound follow-up.
abc
Fig. 35.7 (a) Cross-over catheterization of the right common iliac artery. (b) Selective catheterization of the right common femoral artery. (c)
Superselective catheterization of the right deep femoral artery branch (orange arrow) supplying the pseudoaneurysm (blue arrow)
cd
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ab
375
Fig. 35.8 (a) First coil embolization of the deep femoral artery branch.
(b) Further coil embolization of the branch, with persisting blood supply
of the pseudoaneurysm. (c) Detection and glue-lipiodol mixture emboli-
a
Skin
Pseudoaneursysm
zation of another supplying branch originating from the deep femoral
artery. (d) Final selective angiography with complete closure of the feeding vessels and absence of contrast lling of the pseudoaneurysm
b
Thrombin
Skin
Pseudoaneurysm
c
Closure Device
Skin
Pseudoaneurysm
Fig. 35.9 (a) Percutaneous compression of the pseudoaneurysm neck. (b) Percutaneous thrombin injection. (c) Percutaneous use of a closure
device
Anchor
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O. Moschovaki-Zeiger et al.
Acknowledgments We would like to thank Enrico MoschovakisZeiger and Iason Anastassiou for their assistance in the preparation of
the illustrations.
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Part VI
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Vascular Access
Creating aPercutaneous Arteriovenous
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Fistula: Evidence andTechniques
KylaM.Bennett andAlexandrosMallios
36
A meaningful shift occurred in June of 2018in the arena of
hemodialysis access when the United States Food and Drug
Administration (FDA) approved both the Ellipsys™ Vascular
Access System and the everlinQ™ endoAVF System (soon
to become WavelinQ) [1]. While the need for hemodialysis
has inexorably increased in the population, few advances
have been made in hemodialysis access creation techniques.
As patients live longer, however, the medical community has
noted increasing complications from surgical stulas and
long-term high-ow hemodialysis dependence. This climate
has shaped a market eager for the uptake of new approaches
and devices.
The introduction of these minimally invasive techniques
for arteriovenous stula (AVF) creation promises many
improvements for the burgeoning dialysis-dependent population. Such actual and theoretical developments include
decreased AVF and peri-AVF surgical scarring and vessel
trauma, decreased shear stress (based on the geometry of the
resulting stula and the relative lack of derangement from
the original positions of the involved vasculature) as well as
a much-needed expansion in sites available in the upper
extremity for routine AVF creation. Several Ellipsys studies
have further demonstrated that percutaneous arteriovenous
stulas (pAVFs) require fewer outow vein and cannulation
site interventions as compared to surgical stulas(sAVFs)
[2]. Percutaneous procedures resulting in perforator driven
supercial venous outow allow moderate ow stulas with
shared venous outows resulting in adequate circuit ow
with lower pressure and turbulence in comparison with
sAVFs. Shared venous outow and the proximal forearm
Table 36.1
General
PRA- vs
Brachial
artery- based
CV central venous
Relative benets of pAVF
Ellipsys
• Decreased AVF and peri-AVF scarring from
dissection/trauma
• Decreased shear stress
• Expansion in access site options
• Moderate ow stulas with multiple split
venous outow (decreased pressure and
turbulence)
• Decrease rate of CV, outow, cannulation site
interventions required
• Lower risk of steal syndrome
• Lower risk of arm-swelling
WavelinQ
location of the pAVF also results in extension of standard
cannulation zones [3]. Compared to brachial artery-based
stulas, proximal radial artery (PRA)-based stulas proffer a
lower risk of steal syndrome and arm edema [3–6]; see
Table36.1.
Predictably, some challenges have arisen with the introduction of this new technology and attendant new techniques. Specically, there is an expected learning curve in
the use of the devices (and with Ellipsys in the ultrasound
skill set development). Similarly, there are initial cannulation
challenges as post-procedural patients present to dialysis
centers not yet accustomed to pAVF patients [3].
Device Mechanisms
K. M. Bennett
Division of Vascular Surgery, University of Wisconsin-Madison
School of Medicine and Public Health, Madison, WI, USA
e-mail: bennettk@surgery.wisc.edu
A. Mallios (
Department of Vascular Surgery, Groupe Hospitalier Paris Saint
Joseph, Paris, France
Department of Surgery, Centre Hospitalier de Chartres,
Chartres, France
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_36
*)
While both devices offer a minimally invasive approach to
hemodialysis access creation, they have differing mechanisms of action. The WavelinQ™ (BD) is designed to create
a stulous connection between an artery and a deep vein
which will then ll a supercial vein via the presence of a
perforating vein [7–9]. To do so, the system uses electrodemediated delivery of radiofrequency (RF) energy between
catheters positioned in the artery and deep vein and aligned
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by rare earth magnets (Figs. 36.1 and 36.2). The initial
FDA- approved iteration involved placement of a 6 French
(Fr) catheter antegrade in the brachial artery and venous
access in the brachial (or forearm) veins. In 2019, a 4 Fr
arterial catheter version was approved. This allows access
via the ulnar or radial arteries. Coil embolization of one of
the paired brachial veins at the time of creation is recommended in order to increase ow in the supercial veins
[7–9].
Contrary to the mechanism of WavelinQ, Ellipsys utilizes
thermal energy combined with pressure to fuse the walls of a
perforating vein and the adjacent proximal radial artery
(PRA) (Fig. 36.3) [9–11]. While WavelinQ is performed
under uoroscopic guidance, Ellipsys relies upon ultrasound
guidance alone.
K. M. Bennett and A. Mallios
Fig. 36.1 WavelinQ™ EndoAVF generator with arterial and venous
catheters. Photo of the radiofrequency generator and 4 Fr catheters
Fig. 36.2 WavelinQ™ Venous Catheter with Electrode and Arterial Catheter with Backstop. Schematic illustration of the venous and arterial
catheters with relevant elements for the procedure
ab
Fig. 36.3 (a–d) Stages of anastomosis creation with the Ellipsys device between the proximal radial artery and the perforating vein of the
elbow—reproduced with permission from Mallios etal. J Vasc Surg [11]
cd
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383
Fig. 36.3 (continued)
Access Placement Techniques
ation. Next, the device’s 4 Fr rapid exchange catheters are
placed into the ulnar artery and vein. The attraction between
Both the WavelinQ and Ellipsys devices have undergone
minor changes in technique since their initial introduction
onto the market. The WavelinQ is frequently performed
under moderate conscious sedation with inltration of local
anesthetic. In patients not suitable for moderate sedation, a
regional block is recommended. Initially ultrasound is used
to identify the desired location of the stula based on vessel
diameter. In the rst iteration, this was preferentially at least
4 cm proximal to the elbow. Next, the brachial vein is
accessed using a micropuncture kit after placing a tourniquet proximal to the access site. The brachial artery is then
similarly accessed. Both micropuncture sets are exchanged
for 4 or 5 Fr slender sheaths and brachial arteriogram and
venograms completed. A 0.014″ wire is then positioned in
the ulnar artery. Placing the arterial wire rst allows selection of which of the paired ulnar veins should receive the
second 0.014″ wire. After selecting the correct vein, a catheter is advanced into the vein for ulnar venography. This
allows conrmation of anatomy, presence and location of
the essential perforator, identication of the dominant
supercial venous drainage and planned site for AVF cre-
earth magnets in these rapid exchange catheters facilitates
and maintains correct alignment and positioning. The cath-
eters also provide visual cues to conrm this alignment. One
is the presence of square-shaped lucency in the rotational
indicators at the tip of each of the rapid exchange catheters
[1, 7–9, 12, 13]. It is recommended that this is conrmed in
at least two obliquities (the second being a minimum of 45°
from the rst). The second visual cue is achieved by gentle
forward movement of the venous catheter which indents the
convex electrode in this catheter over the concave ceramic
plate in the arterial catheter. When proper positioning is
conrmed, the venous catheter is connected to an RF gen-
erator and the wires pulled back to be proximal to the align-
ment zone of the convex electrode and concave ceramic
plate. The generator is then activated using a 0.7-s pulse
effectively vaporizing the tissue at the electrode-plate inter-
face and creating a side- to- side AVF.Successful AVF cre-
ation is conrmed via brachial sheath arteriography. This
also allows documentation of ow within the perforator dis-
tributed to the supercial veins. Oft, the operator will embo-
lize the access brachial vein to encourage further ow to the
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K. M. Bennett and A. Mallios
supercial system via the perforator. It is not uncommon to
see minor contrast extravasation on this completion study
immediately following AVF formation though this should
resolve within 10min [7, 12, 13]. Any observed ulnar vein
spasm requires pharmacological treatment to prevent nontransient extravasation. More recently, the introduction of
dual small caliber 4 Fr catheters have expanded access
options to use the wrist as the access site for arterial cannulation [14].
The Ellipsys procedure is typically performed under
supraclavicular block combined with sedation. After proximal brachium tourniquet placement, the medial cephalic/
cubital vein is accessed with a micropuncture needle a few
millimeters proximal to the perforating vein (PV). Using
small movements with both the ultrasound probe and the
needle, the micropuncture needle is advanced into and along
the perforator with care taken to remain in the center of the
vessel. Where the PV traverses closest to the proximal radial
artery (PRA), the process is continued until the needle tip is
advanced into the center of the PRA.There is clear tactile
feedback when the radial wall is crossed. As long as the
puncture has not been prolonged, the needle should now
have low-pressure pulsatile ow. The 0.021″ wire of the 6 Fr
slender sheath is then advanced through the needle and down
to the distal radial artery at the wrist. The needle is removed,
and the sheath is advanced over the wire such that it crosses
into the artery. Now, 50 units/kg of heparin is administered.
The wire is replaced with a 0.014″ Nitrex wire (ev3;
Plymouth, MN). The Ellipsys catheter is placed over the wire
into the sheath so that the tip of the device is in the artery and
the base of the jaw in the vein [15]. The sheath is retracted to
demonstrate the jaws of the device on ultrasound. After correctly orienting the device, it is gently retracted until it
engages (in both tactile and visual perception) the wall of the
PRA.The jaws of the device are then closed capturing the
arterial and venous walls (Fig. 36.1). Appropriate capture
and position is conrmed as the device generator displays
the attendant distance measured between the jaws. The generator is then activated creating the anastomosis (Fig.36.3).
The device is removed and an 5mm×2cm compliant angioplasty balloon is inated for 2min across the anastomosis.
Fistula ow is then conrmed by duplex [16]. And all wires
and devices are removed and a brief period of manual pressure ensues [2, 15].
Anatomic Applicability
Instructions for Use (IFU) for each device provide information regarding anatomic requirements. True applicability determination requires consideration of whether these
criteria are simply necessary or both necessary and suf-
cient. WavelinQ’s IFU requires ulnar vein and ulnar artery
diameters both be a minimum of 2mm and the distance
between the ulnar vein and artery be less than 2mm. The
newer 4 Fr version of the WavelinQ device allows use of
the radial artery and vein if they meet the same size and
proximity requirements as those for described for the ulnar
vessels [12].
The Ellipsys IFU requires that the proximal radial artery
and perforating cubital vein both have diameters of at least
2 mm. The distance between the PRA and the perforating
cubital vein must be less than 1.5mm [9, 14, 17].
While these are the IFU-delineated requisites, the truth is
that both techniques rely directly or indirectly upon the presence and adequacy of a perforating cubital vein. Both also
require a minimum of one supercial upper arm draining
vein (cephalic or basilic) for future cannulation. The minimum acceptable size is likely 2mm for both required venous
elements [9]. The distinction between IFU elements and anatomic essentials is important due to the evident wider spread
applicability of WavelinQ based on IFU alone.
Considering a single Veterans’ Affairs cohort, and applying IFU criteria and an algorithm necessitating the use of
surgical distal radiocephalic stulas followed by percutaneous/endo stulas followed by antecubital stulas and then
grafts, a group evaluated both IFU-based and real world utility of pAVFs in 116 extremities in 58 men [9]. Starting with
IFU criteria alone, they reported that 93% of extremities
were suitable for WavelinQ and 52% for Ellipsys. However,
52% of these also had adequate vasculature to support a distal radiocephalic. When the authors added in real-world
necessities such as adequate draining supercial vein and
present and adequate perforating vein, system usability
decreased to 55% for WavelinQ and 44% for Ellipsys. When
they excluded those that should preferentially receive a distal
radiocephalic, they discovered that 32% of the patients
would be appropriate for WavelinQ and 23% for Ellipsys—
given differing requirements, this resulted in an overall 69%
rate of adequate anatomy for some form of percutaneous stula; see Table36.2.
Table 36.2 Anatomic Requirements for pAVFs
Ellipsys WavelinQ
IFU vessel
diameter
IFU distance Perforator-PRA
Non-IFU (real
world)
PRA proximal radial artery
Perforating cubital
vein ≥2mm
PRA ≥2mm
<1.5mm
Supercial outow
vein >2mm
Ulnar (or radial) vein ≥2mm
Ulnar (or radial) artery
≥2mm
Ulnar (or radial) vein-artery
<2mm
Supercial outow vein
>2mm
Perforating cubital vein
presence and diameter >2mm
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